North Carolina

North Carolina Strategies

Addressing Challenging Behaviors and Supporting Social-Emotional Development in Early Care and Education Classrooms: North Carolina Healthy Social Behaviors Project

North Carolina’s Healthy Social Behaviors Project (HSB) helps licensed child care centers serving children birth to five to address challenging behavior and support social-emotional (SE) development. An important goal of HSB is reducing the use of exclusionary practices. HSB was established in 2005 as a response to national research on the high prevalence of expulsion and suspension in state prekindergarten programs. While this research did not include private licensed child care centers, leaders in the state believed these programs would benefit from social-emotional-focused supports. The state’s child care licensing division does not have a policy banning exclusionary practices, but defines them and discourages programs from using them.

HSB services are available statewide to licensed child care centers, which includes Head Start and state prekindergarten programs. Services are delivered by HSB teams in 14 multi-county child care resource & referral (CCR&R) networks. HSB offers a continuum of services based on the Pyramid Model. These include professional development (two-hour trainings and more intensive five-hour trainings earning continuing education units (CEUs)), foundational technical assistance (TA) offered virtually in groups, and in-person crisis TA in the classroom.

HSB trainings and CEUs fill key gaps in early care and education (ECE) teachers’ college coursework because most teacher education programs in North Caroline state do not cover the types of SE strategies offered by the Pyramid Model until graduate-level studies. Each HSB specialist delivers 12-15 of these two-hour trainings and CEUs a year.

For TA services, only center directors may submit requests to HSB, though often they are submitting on behalf of classroom teachers. The HSB team in the CCR&R region serving the center receives the request and within a week an HSB specialist calls the director or holds an in-person meeting. During this meeting, the HSB specialist learns about the center and teachers’ struggles with challenging behavior, and describes the services HSB offers and what it does not do (e.g., give the center permission to expel a child). The HSB specialist also conducts at least one in-person observation of the center, based on a list of Pyramid Model key practice strategies derived from the Pyramid Model Key Practice Checklist, to assess teachers’ use of Pyramid Model practices.

Based on the in-person observation, centers that are not using Pyramid Model strategies extensively are referred to foundational TA, which is 10 months of virtual group coaching focused on the use of Pyramid Model strategies. Centers that are already using Pyramid Model strategies more widely receive crisis TA, as well as some foundational TA if needed. While crisis TA is focuses on teacher practices, it is usually requested due to the challenging behavior of an individual child. For crisis TA, the HSB specialist conducts additional 60-90 minute weekly observations for 4-6 weeks to allow collection of Pyramid Model practice data on which action plans are built. The specialist works with the teacher to develop an action plan and supports its implementation; the entire process typically lasts nine months. Crisis TA comprises the largest part of the HSB coaches’ workload; with the time an HSB coaches spends delivering crisis TA in a month, she can provide 7-9 centers with foundational TA.

Currently all HSB coaches have full caseloads and waitlists. Centers are served on a first come, first served basis, apart from requirements to ensure HSB coaches are serving equitable numbers of centers in each county in their CCR&R network. In response to waitlists, HSB introduced a helpline staffed by Pyramid Model experts who can help answer questions—via phone and online questionnaire—and suggest strategies to centers that cannot be immediately assigned an HSB specialist.

Having been around since 2005, HSB has established strong relationships with other providers that regularly interact with ECE programs (e.g., CCR&RS, licensing consultants, other TA providers) which has encouraged these providers to refer programs to HSB.

For outreach, HSB coaches conduct cold calls to centers with new directors and to centers they have not heard from before. They attend regional director meetings two to four times a year, and whenever they deliver trainings they include information about the continuum of HSB services. All child care licensing consultants are also updated on HSB regularly. When they go to a new center, the licensing consultant informs the center about HSB. The state Division of Child Development and Early Education sends a weekly e-blast to all licensed centers and includes information about HSB a couple of times a year. Each CCR&R network also sends information in its e-blasts.

The highest volume of referrals comes from teachers who have learned about the full range of HSB services while attending an HSB training, and asked their director to submit a request. Next are referrals through HSB partnerships with other TA consultants (e.g., child care health consultants, quality consultants) who notice a center might need support around challenging behaviors. Last are referrals from licensing consultants; their guidance is the weightiest and most likely to be acted on by a director. Also, if a center has a licensing infraction and action plan, especially in an area related to managing challenging behavior or transitions, staff may be mandated to attend HSB trainings.

While HSB does not support families directly, it develops resource lists that are customized for each region and are updated annually. It includes a range of resources in community, including mental health services, and assistance with basic needs such as housing and food. These resources lists are provided to parents by the HSB specialist or center staff.

Workforce Development

Currently HSB has 32 full-time coaches working across the state, as well as 5 fidelity coaches and 3 helpline staff. Each of the 14 regional CCR&Rs has up to four HSB coaches. Based on HSB caseloads and estimates of demand, HSB would need at least 14 additional coaches to operate without waitlists.

HSB coaches have a master’s degree in early education and a minimum of three years of experience as a teacher or directors. All coaches are in the process of receiving IECMH endorsement from the North Carolina Infant and Early Childhood Mental Health Association. HSB specialist preservice training includes the Pyramid Model, practice-based coaching, master trainer coaching, and trauma-informed training. Two HSB project managers deliver the orientation and ongoing training, as well as monthly group reflective supervision and individual consultation to HSB coaches as needed. HSB coaches also meet regularly with their local supervisor.

Additionally, the HSB team participates in two face-to-face three-day professional development meetings annually. HSB project managers also host about one-third of the team annually at the National Training Institute on Effective Practices: Addressing Challenging Behaviors (NTI).

Financing

The HSB budget, including both personnel and operating funds, exceeds $4 million annually and is funded by the North Carolina Division of Child Development and Early Education using Child Care Development Fund quality set-aside funds.

Evaluation and Monitoring

HSB coaches enter data on TA into a statewide database. They collect data about the center size, whether it serves children receiving a child care subsidy, its quality rating and improvement system star rating, and the nature of the request for TA. For each classroom served, they collect children’s age level and enrollment data, along with the number of children with special needs and the number of children displaying challenging behaviors. Coaches collect classroom teacher demographic characteristics, education, and experience, as well as information about which classrooms are receiving foundational or crisis coaching and how long the crisis coaching lasts.

Coaches complete logs for each individual coaching visit, which allows tracking of teachers’ success at completing goals on action plans and whether any children were expelled. If a child is expelled, HSB collects demographic data on the child, the reason for the expulsion, and any interventions or community resources recommended prior to expulsion.

HSB coaches also complete tracking reports on each training delivered. Training reports track the county and method of delivery, whether it was in response to a licensure corrective action plan, the title of training, number of hours, and number of participants. Pre-post training surveys use a 5-point Likert scale based on the objectives set for the training module, and the post training survey also includes a satisfaction question.

Special thanks to the following individuals at Healthy Social Behaviors Project for providing information for and reviewing this profile: Smokie Brawley, State Project Manager, and Josh Byrd, Assistant Project Manager.Last updated June 2024

Maternal Depression Screening and Response

North Carolina’s Medicaid both pays for maternal depression screening (MDS) as part of well-child visits, and also offers support to providers to promote effective MDS and response to positive screens. This support includes clear guidance about conducting screening and referring the parent and child to appropriate services, resources for identifying services for the parent and dyad, learning communities for providers, and data to help the provider self-monitor the delivery of MDS. In addition, North Carolina provides access to case-management for very young children whose mothers are experiencing depression. The organization responsible for Medicaid service delivery in North Carolina, Community Care of North Carolina (CCNC), has developed a suite of policies and supports that help ensure the well-being and healthy development of infants and young children who are at-risk due to maternal depression.

A comprehensive maternal depression toolkit for screening, referral, and follow-up gives providers easy access to key resources, including background on the value of maternal depression screening; guidance on screening tools, an algorithm for deciding when and how to respond to elevated scores, and information on management and treatment options, and guidance on provider-to-provider communications about results. The toolkit highlights the need for referral of the parent and child to relationship-based dyadic treatment and to a care coordination program called CC4C (discussed below). In addition, guidance stresses the need for follow-up social-emotional screening of the child, in response to a positive parent screen.

North Carolina Medicaid helps providers improve their practices related to maternal depression screening and response in several ways. In addition to the toolkit, CCNC can provide pediatricians with materials they can use to complete a course on maternal depression and receive maintenance of certification (MOC) credit. The course covers screening policies and procedures, the negative impacts of maternal depression on the infant, and referral practices for the mother and the mother-infant dyad. Another critical support provided by CCNC is feedback to providers. Each quarter, providers receive their MDS rates so that they know their performance on this indicator. The system’s quality improvement specialists also visit practices and can help providers increase their rates by encouraging their use of the toolkit and maternal depression MOC course, and providing individualized assistance.

Financing

North Carolina Medicaid pays for up to four maternal depression screenings in the child’s first year, conducted during well-child visits. Providers bill for the screenings under the child’s Medicaid.

Monitoring and Evaluation

This suite of supports for MDS has produced high rates of screening in North Carolina. In a 14-month period ending in March 2018, MDS ranged from 72 percent to 87 percent across providers. As of the first quarter of 2019, 43 percent of mothers of 6 month olds had received at least one maternal depression screen, an increase from 38 percent in the fourth quarter of 2018.

Last updated October 2019

Case-Management/Linking Families to Services

CC4C is a case-management program for children birth to five years who are experiencing risk factors for poor health outcomes and who require health and related services beyond those required by most typically developing children. Children whose mothers are experiencing maternal depression are eligible for CC4C services. Other children who can participate in CC4C include children with behavioral and mental health conditions, children in very low income households with continuous chaos, including parent substance abuse, children in foster care, and children experiencing abuse or neglect. CC4C serves close to 10 percent of Medicaid eligible children age 0 to 5 years in North Carolina.

Enrolled children receive services in a medical home. Case managers, who are nurses or social workers, conduct an assessment of family needs with The Life Skills Progression. This tool measures the adequacy of support systems, parent education and employment, health care, mental health and substance use, and access to basic needs. Results guide efforts to secure assistance for families to meet a wide range of needs to help reduce family stress and ensure that children’s health and mental health needs are met. Case managers connect with families through home-visits, phone calls, and visits with families to the pediatrician.

A CC4C workgroup meets monthly to help guide the work of the program. Members are representatives of the NC Division of Medical Assistance, Division of Public Health Early Intervention, the physician community, and local health departments.

Financing

CC4C is financed through Medicaid and Title V (Maternal and Child Health Services Block Grant Program). Each public health department receives a “per month per member” payment based on the county population of 0-5 year olds; this payment covers full-time staff of CC4C in each county.

Monitoring and Evaluation

North Carolina is currently transitioning to managed care. The NC Department of Health and Human Services has developed a plan for maintaining the core activities of CC4C. During a two-year transition period, a clinical leadership team will develop quality measures for case-management that will be carried out in managed care organizations and existing entities that operate CC4C.

Last updated October 2019

Parenting Programs: Triple P

Positive Parenting Program (Triple P) is an evidence-based program that teaches parents of children from birth to age 17 strategies to promote social competence and self-regulation in children. Triple P consists of five tiers, with two universal tiers designed for all parents and three tiers of targeted supports for families with greater needs. Level 1 is a community-wide media campaign. Levels 2 through 5 can be delivered in group formats, and levels 4 and 5 can be delivered individually. Triple P can be delivered in a number of settings, including the home, community agencies, healthcare settings, schools, and online. This profile provides a description of Triple P as it is being implemented state-wide in North Carolina. The state-wide profile is followed by a description of how Triple P is being delivered to families with children birth to age 5 in Mecklenburg County along with a Triple-P-based program (PECE) for staff in early care and education programs.

In 2017, North Carolina began the process of statewide implementation of Triple P. The partners in this effort include the state’s Department of Health and Human Services, Division of Social Services and Division of Public Health; The Duke Endowment; Triple P America; Frank Porter Graham Child Development Institute (FPG); and Prevent Child Abuse North Carolina.

In-person Triple P courses are offered in 48 of North Carolina’s 100 counties, with widespread implementation in approximately 36 of those counties. Originally counties could choose an age range to focus on (0-5, 0-8, or 0-17), but a commitment to serving the entire 0-17 age range has led to the scaling up of in-person course offerings for all age bands across the state. For parents unable to participate in person, Triple P is also available free online for all North Carolina parents.

For statewide implementation of Triple P, North Carolina counties have been grouped into 10 regional service coalitions, each led by a local implementing agency (LIA), typically a county public health department, and comprised of local family service agencies, schools, and organizations that deliver Triple P services. Each LIA is staffed with at least three full-time positions to coordinate and support community-wide implementation with fidelity to the Triple P model. These coordinators work with Triple P service providers in the area on implementation planning; outreach to parents and practitioners; practitioner training and fidelity support; and data collection and reporting.

Triple P coordinators also participate in the North Carolina Triple P State Learning Collaborative (SLC), supported by Triple P America and the North Carolina Triple P State Leadership Team. The SLC meets quarterly to engage in county-level peer support and improve Triple P across the state.

LIAs develop contracts with the Triple P providing agencies that cover the type and number of Triple P services to be delivered, and include a commitment on the part of agencies to collect and send data to the state, commit to delivering Triple P with fidelity, provide practitioner supports and conduct outreach. Individual counties have written agreements with between 10 and 40 agencies. A wide range of service agencies deliver Triple P, including schools, mental health agencies, faith-based organizations, health departments, and pediatric practices. LIAs and agencies work together to identify gaps in services (e.g., level 2 is well-covered, but there is unmet demand for level 4) and determine whether and how to expand.

Individual Triple P practitioners are trained in cohorts of 20, with each Triple P level and format having its own, evidenced-based training. During the early stages of scaling up it was easy to recruit individuals for training. Now, when new providers are often trained to maintain the workforce and make up for attrition, LIAs help bring together individuals from different regions to comprise a 20-person cohort. Individuals with a wide range of backgrounds participate in Triple P trainings, and include paraprofessionals, child care center directors, social workers, public health professionals, parent advocates, and nurses.

Varied strategies are used in outreach to families. Triple P Level 1 is a public awareness campaign focusing on positive parenting information and messages. In North Carolina, materials have included posters, brochures, flyers in medical waiting rooms, and a parent newsletter (left in grocery stores, school districts, local papers, yoga studios). Additional methods to inform parents about Triple P have included the use of Google AdWords, press releases, movie commercials, billboards, yard signs, and banners at public events. For more intensive Triple P levels (4 and 5), mental health and social services agencies often recruit from the families they are already serving.

FPG’s Implementation Capacity for Triple P (ICTP) project supports the scale-up of Triple P by providing training and technical assistance to Triple P coordinators, Triple P agency leaders, statewide funders and policymakers, and organizations in North Carolina. It has developed implementation support plans and quality improvement tools to assist communities during the implementation process.

Financing

Funding for LIA activities, including coordination, training, outreach, and materials, comes equally from the Division of Public Health (through federal Title V Maternal and Child Health Services Block Grant funds with a state match) and from the Division of Social Services (with a legislative appropriation as a line item in the child welfare budget). Total funding from these two sources is $4 million a year. The Duke Endowment funds the FPG Implementation Capacity for Triple P project. Funding for online Triple P totals $1.7 million and comes from the federal Maternal and Child Health Block Grant and state funding through DPH and DSS.

Triple P courses provided at the local level are funded through a variety of mechanisms. LIAs work with service providers to secure funding for Triple P courses, and a wide range of models are employed. Examples include Medicaid reimbursement, agencies covering the cost themselves, and charging course participants.

Evaluation and Monitoring

A meta-analysis of more than 100 studies of Triple P found positive effects on children’s social-emotional and behavioral outcomes and parenting practices, including for children from birth to five (for information on Triple P see parenting program research summary).

Local implementing agencies are responsible for coordinating the collection of administrative and monitoring data from Triple P providers in their region. (See the profile section on Mecklenburg County for examples of data collected.)

FPG’s ICTP has also been responsible for evaluating the implementation of Triple P. An initial implementation evaluation, which included a qualitative component, focused on Cabarrus and Mecklenburg Counties from January 2014 through December 2015. ICTP conducted regional workshops to share lessons from the evaluation and support Triple P implementation across the state.

Findings from the evaluation identify a number of factors associated with counties’ successful implementation of Triple P. Agencies implementing Triple P were more likely to continue providing Triple P services during the study period when they had Triple P implementation teams of at least three members with adequate time and effort to support daily implementation and when they had more than one practitioner providing Triple P services. The evaluation also identified a need for increased use of best practices in both coaching for practitioners and fidelity assessment. The evaluation suggests use of these practices can increase the quality of delivery of Triple P services, as well as how often practitioners use Triple P with their clients. Supporting these findings on the importance of provider supports, a separate study of Triple P in seven North Carolina county or country clusters found that Triple P providers who attended peer support sessions used Triple P with more parents.

The FPG ICTP implementation evaluation also examined county-level child maltreatment indicators over time and found a two-year drop in the rate of substantiated child maltreatment reports for children birth to age 17 after Triple P practitioner training was initiated in Cabarrus County. FPG evaluators cautioned against drawing causal inferences from the outcome results since other factors may have contributed to the drop.

Another study of Triple P examined the relationship of child maltreatment indicators to state-funded implementation of Triple P in 34 of North Carolina’s 100 counties in 2012 and 2013. Comparing children birth to 18 in counties with and without Triple P implementation, findings for Triple P counties showed small but significantly greater reductions in investigated child maltreatment reports and foster care placements, but not emergency department visits for suspected child maltreatment.

The FPG ICTP also supports ongoing monitoring, which focuses on three outcomes in North Carolina counties scaling-up Triple P: substantiated child abuse and neglect, out-of-home foster care placements, and emergency department visits indicating child injury.

Mecklenburg County: Focus on Triple P for Birth to Five

In the past year more than 8,000 children age birth to five were served with Triple P in Mecklenburg, the state’s second most populous county. Nearly 4,000 children were served by Positive Early Childhood Education (PECE), an evidence-based program designed for ECE settings and introduced in Mecklenburg in 2019. PECE teaches ECE staff to use Triple P practices, and can be used in conjunction with Triple P parenting programs to provide consistent supports for children’s self-regulation and positive behavior across home and ECE settings. A total of 229 early care and education (ECE) classrooms in 28 child care facilities and 41 elementary school prekindergarten programs participated in PECE. In PECE settings, the ECE program director is trained in PECE and Triple P, while classroom staff take four online PECE modules and receive four hours of coaching. ECE programs conduct seminars with parents and refer parents with greater needs to Triple P level 3 classes.

Parents of an additional 4,800 children birth to five were served by traditional Triple P classes in the past year in community settings such as pediatric offices, churches, schools, mental health agencies, and libraries. Referrals to these classes come from child care centers, pediatric offices, public health agencies providing families with case management services, and the library system.

In cases where Triple P is delivered by a licensed clinician, level 2 can be billed to Medicaid as anticipatory guidance. Medicaid can also be billed for higher levels of Triple P if the child has a diagnosis. Stakeholders are working with the state Medicaid agency to allow trained providers who are not licensed clinicians (e.g., health educators) to bill Medicaid. Medicaid is also exploring CPT codes for Triple P-trained, licensed clinicians that would allow enhanced rates of reimbursement.

Mecklenburg County has around 500 trained Triple P providers, with 250 actively delivering Triple P. Fewer than half of Triple P providers are licensed clinicians. At lower levels, Triple P can be delivered by a variety of non-clinicians such as librarians, health educators, and non-clinical staff in pediatric settings. Training and post-training peer support for providers includes guidance about recognizing families’ needs for referrals to more intensive services, including higher levels of Triple P and parent mental health services.

Evaluation and Monitoring

As part of PECE implementation, programs collect data on parent seminar participants, parent and teacher perceptions of home-school connections, and teacher perceptions of classroom climate. Parents and teachers are encouraged to submit a Strengths and Difficulties Questionnaire, which screens for children’s social-emotional problems. See above description of state-wide Triple P for information on evaluations.

Financing

Funding for Triple P training, support services, and systems coordination comes from Title V Maternal and Child Health funds, as well as an additional birth to five grant from the state’s Improving Community Outcomes for Maternal and Child Health initiative. (See description of state-wide financing, above, for other funding information.)

Last updated May 2020

Special thanks to the following individuals for providing information for and reviewing this profile: Marian Earls, Director of Pediatric Programs, Community Care of North Carolina; Sara van Driel, Implementation Consultant, Triple P America; and Cathy Henderson, Health Manager, Mecklenburg County Public Health.